ASVMEB Complaint 21-45 In re: Courtney Deer

VICTORIA WHITMORE
~ EXECUTIVE DIRECTOR -

DOUGLAS A. DUCEY
~ GOVERNOR -

ARIZONA STATE VETERINARY MEDICAL, EXAMINING BOARD
1740 W. ADAMS STREET, STE. 4600, PHOENIX, ARIZONA 85007
PHONE (602) 364-1-PET (1738) #FAX (GO2) 364-1039

VETBOARD.AZ.GOV

INVESTIGATIVE COMMITTEE REPORT

TO: Arizona State Veterinary Medical Examining Board

FROM: PM Investigative Committee: Adam Almaraz - Chair
Amrit Rai, DVM
Cameron Dow, DVM
Brian Sidaway, DVM

STAFF PRESENT: Tracy A. Riendeau, CVT - Investigations
Marc Harris, Assistant Attorney General

RE: Case: 21-45

Complainant(s}: Frederick Milens/Ashanna Biliter

Respondent(s): Courtney Deer, DVM (License: 6576)

SUMMARY: APPLICABLE STATUTES AND RULES:
Complaint Received at Board Office: 10/16/20 Laws as Amended August 2018
Committee Discussion: 4/6/21 (Lime Green); Rules as Revised
Board IIR: 5/19/21 September 2013 (Yellow)

On June 19, 2020, “Camm a 14-year-old male Pomeranian was presented to 15! Pet
Veterinary Centers after two day history of collapsing. The dog had multiple medical issues
and was under the care of an internal medicine specialist and neurologist.

Diagnostics were conducted; it was initially suspected the dog had IMHA and a blood
transfusion was eventually performed at BluePearl.

The dog continued to decline, was evaluated and hospitalized for care and treatment at
1s’ Pet Veterinary Centers for possible seizures. The dog was obtunded and worsened despite
treatment. All of the dog's care providers were concerned with the dog's prognosis and
quality of life due to the dog's mental status not returning.

On June 26, 2020, Complainants elected to humanely euthanize the dog.

Complainants were noticed and appeared telephonically with attorney, Kyle O’Dwyer.
Respondent was noticed and appeared telephonically. Attorney David Stoll appeared.

21-45, Courtney Deer, DVM

The Committee reviewed medical records, testimony, and other documentation as described below:

e Complainani(s} narrative: Frederick Milens/Ashanna Biliter
e Respondent(s) narrative/medical record: Courtney Deer, DVM
e Consulting Veterinarian (s) narrative/medical records: Jill Patt, DVM

PROPOSED ‘FINDINGS of FACT’:

With respect to Dr. Deer, Complainants allege that Dr. Deer failed to administer the dog any
medication for almost half a day, making it difficult to determine what was causing the
dog's issues. Additionally, Complainants allege that the dog was nof monitored closely;
there was not a “jingle collar” or other device used to inform them when the dog was having

Q Seizure.

Complainants were also concermed with Dr. Deer's comments to another premises stating
Complainants were having difficulty not understanding it might be time. If they had known
her opinion, they would have sought out care elsewhere. Complainants also did not fee! Dr.
Deer advised them of when the dog's status declined on June 24") and believe she did not
reach out to Dr. Schnier to discuss the dog current status as requested.

1. Dr. Schnier stated that he had worked with the complainants since the fall of 2018 as an
internal medicine specialist. At that time, the dog was evaluated at VETMED where he was
diagnosed with a pheochromocytoma involving his left adrenal gland. The
pheochromocytoma was resected by a surgeon at UC Davis in December 2018. Dr. Schnier
continued to work with the dog and his owners since that time and had re-evaluated the
dog numerous times at VETMED and later at BluePearl.

2. Dr. Yeamans stated in her narrative that the dog had been under her premises's care for
progressive seizure disorder and suspected meningoencephalitis of unknown origin since
November 2019.

3. On June 19, 2020, Friday, (approx. 4:30em) the dog was presented to Dr. Meredith at 1*
Pet Veterinary Centers after collapsing. The dog had a history of multiple medical issues and
had been on a combination of seizure medication. Complainants reported that the dog laid
lateral in the yard and had turned his head to the side. The dog also had two previous
episodes at home that started the night before. There was also an episode that happed
later in the day where the dog had urinated on himself and iurned pale. Upon exam, Dr.
Meredith noted the dog was responsive, had muddy gums and breathing difficulties. The
dog's neurological exam was abnormal — non menace response in either eye. The dog's
heart rate was low and lungs harsh. An !V catheter was placed and the dog was put in an
oxygen chamber.

4. On intake the dog had a respiration rate = 30rpm, white mucous membranes, pulse rate =
80bpm (the minutes later 150bpm); temperature = unable to obtain. After being placed in

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21-45, Courtney Deer, DVM

the oxygen chamber, ECG revealed a normal rhythm and rate, as well as normal blood
pressure. Once the dog had received oxygen therapy, blood was collected for testing and
thoracic radiographs were performed.

5. Radiographs revealed a mildly enlarged heart with a bronchial pattern worse in the left
lung fields, spondylosis, and aeophagia. The radiology report noted collapse of the left
bronchius, enlarged liver, and some abnormal gastric contents. Blood work revealed anemia
(PCT — 22%, RBC — 2.47), and a saline agglutination test was run and there was a concern for
agglutination.

6. Dr. Meredith discussed the abnormal findings with Complainants. Complainants advised
Dr. Meredith that the dog had kidney disease as well as a left sided stroke and absent
menace of the right eye. Dr. Meredith relayed the possibility of immune mediated hemolytic
anemia (IMHA} due to the anemia and elevated WBC - she felt that primary IMHA was
unlikely due the dog’s age, and secondary IMHA could be related to an underlying
infection, medications, cancer, and other. Dr. Meredith also expressed concern for
pulmonary thromboembolism (PTE), considering the dog’s history of stroke and oxygen
dependence.

7. Dr. Meredith discussed at length possible underlying causes, and that they could treat with
steroids, antibiotics, and oxygen at that time. They would continue to monitor the dog’s
response. Due to the dog’s myriad of other health issues, the dog's prognosis was guarded
to poor, and Complainants were advised that if the dog continued to have issues, they may
need to discuss the dog's quality of life. Complainants understood and approved the plan
for hospitalization. The dog was hospitalized on IV fluids 8.8mLs/hr (unclear on type).

8. At 7:000m, Dr. Meredith's associate, Dr. Deer, took over the care of the dog. Dr. Deer
stated in her narrative that dog had an extensive history of hydrocephalus, seizures, Chiarai
malformation, syringomyelia, medially luxating patellas, hypertension, hypothyroidism,
collapsing trachea, IVDD, a surgically removed pheochromocytoma a few years prior, and
a suspected fractured right thoracic limb (prior to adoption of the dog). The dog had
elevated renal values that have been identified by the regular veterinarian earlier in the
year. The night before presentation the dog had a seizure with collapse and white mucous
membranes. The dog had been unable to stand which was normal for him as he had not
been ambulatory for some time.

9. After Dr. Deer reviewed Dr. Meredith's findings (blood work and radiograph results), she
examined the dog and found a weight = 3.4kg, a temperature = 98.2 degrees, a heart rate =
170bpm and a respiration rate = 40rom; pale mucous membranes. Dr. Deer stated the dog
was quiet, alert, and responsive; although the dog became tachypneic during the exam but
was not in respiratory distress. The dog was non-ambulatory and Dr. Deer did not perform a
full neurologic exam due to the dog needing to be in the oxygen chamber. The dog was
offered food and water - ate well - and was medicated with prednisone, zonisamide,

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levothyroxine, imepitoin, flowvent, and telmisartan at 8om.

10. That evening, dog was also administered Ampicillin, levetiracetam and dexamethasone
sodium phosphate IV.

11. In the early morning, blood work was repeated. When removed from the oxygen kennel
the dog would become stressed therefore the dog remained on oxygen. Blood work
revealed PCV 20% and Dr. Deer coniacted Complainants. She relayed the worsening
anemia and the differential diagnosis of IMHA and causes. Complainants asked if the
zonisamide or phenobarbital could be the cause — Dr. Deer thought it was unlikely but they
could try tapering zonisamide if recommended by the neurologist, but the dog would at risk
for continued seizures. Additionally, stopping the zonisamide would not slow the IMHA if that
was the cause. Due to the worsening anemia, blood transfusion was discussed as a possibility
as well as the dog’s quality of life and humane euthanasia. Complainants were not
interested in humane euthanasia at that time.

12. Complainant requested Dr. Deer reach out to Dr. Schnier — internal medicine at BluePear|
Avondale - and Dr. Yeamans — neurologist at ANIC — to discuss next steps. Dr. Deer explained
that she would not be able to get ahold of either of them at that time {lam) but she would
call BluePearl to update them. Within the hour, Dr. Deer called BluePearl to advise the dog
was currently being hospitalized with them and fo left Dr. Schnier know that Complainants
were interested in consulting with him.

13. On June 20, 2020, at approximately 6:30am, Dr. Deer contacted Complainants with an
update on the dog. She advised that the dog was still on oxygen therapy and that she had
reached out fo BluePearl to let them know the dog was hospitalized with them. It was
unlikely they would get a consult on the weekend, but they would let Dr. Schnier know. Dr.
Deer discussed the plan of potentially lowering the zonisamide and that the blood work was
partially consistent with IMHA but was not the definitive diagnosis. Shortly after the call, the
dog's care was transferred to Dr. Meredith.

14. At 8:00am, the dog was medicated with the owner's medication and Dr. Meredith
continued supportive care for the dog throughout the cay.

15. At 11:00am the dog had a PCV = 22% and at 3:00om the dog had a PCV at 23%.
Attempts were made to wean the dog off oxygen throughout the day. Complainants visited
the dog and elected to take the dog home as he appeared more relaxed while with them.
Dr. Meredith recommended Complainants keep their previously scheduled appointment
with Dr. Schnier on Monday. The Gog was discharged to Complainants.

16. On June 21, 2020, at 4:00am, the dog presented to Dr. Deer at 15" Pet Veterinary Centers
due to another episode of collapse. Complainants reported that they took the dog outside
where he collapsed, was pale and non-responsive. According to Dr. Deer, she evaluated

21-45, Courtney Deer, DVM

the dog — he was QAR, unable to ambulate, was tachypnic, and had mild to moderate
increased abdominal effort with an increase in bronchovesicular sounds in all lungs. The dog
had a PCV — 22% consistent with the last reading the previous day. Could not locate the
medical record for this day.

17. Dr. Deer spoke with Complainants and discussed that the dog appeared to be back to
the same condition he was the previous day. They discussed causes of the dog's collapse
and hospitalization for care until the evaluation at BluePearl. They further discussed a
cardiology consult to evaluate pulmonary hypertension and if there was cardiac issues.
Complainants were interested in the cardiology consult. Since it was Sunday at 4am, Dr.
Deer explained that it was unlikely they could secure a consult right away. The dog was
given back to Complainants to wait in the car while Dr. Deer reached out to specialists.

18. Dr. Deer reached out to Dr. Church — he was out of town; she contacted VETMED and
was advised that an echocardiogram and cardiology consult was unlikely on Sunday or
Monday. Dr. Deer reported her unsuccessful attempts to find a cardiology consult for
Complainants and recommended follow up care at VETMED until the cardiologist could
evaluate the dog. Complainants elected to take the dog home and monitor him.

19. Complainants called BluePearl to advise the dog was being seen at 151 Pet Veterinary
Centers in Mesa and asked if Dr. Schnier could call and discuss the dog's care with the vets
at 1s Pet Veterinary Centers. BluePearl staff advised Complainants that Dr. Schnier was not
on-call but they would text Dr. Schnier and let him know the issues the dog was having.
However, the dog issues were new and Dr. Schnier would not be able to provide any
information other than the dog’s history. BluePearl staff would call 1" Pet Veterinary Centers
to discuss.

20. BluePearl staff called 1' Pet Veterinary Centers and spoke with Dr. Deer. She was advised
that Dr. Schnier was not on call all the time but would be texted to update him on the dog.
Dr. Deer reported that the dog had been presented a few days ago and it was
recommended Complainants follow up with an internal medicine doctor which was not
done — however the dog would be seen on Monday. Dr. Deer further stated that
Complainants were having difficulty understanding that it might be time.

21. Complainants stated that Dr. Deer did not inform them of her opinion at that time. If she
had, they would have had sought out a different provider.

22. At 7:000m that evening, Dr. Deer returned to work. She had a message from
Complainants; she returned the call and was told that the dog was okay but sedate. They
were unsure if the dog was sedate due to the illness or the medications — the dog was resting
well and eating and drinking.

23. On June 22, 2020, the dog was presented to Dr. Schnier for evaluation. Dr. Schnier

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21-45, Courmey Deer, DVM

reviewed the dog's diagnosis/problem list:

Gaon i a ee SO ee Ocal. GO

Hind limb neuropathy/myopathy;

Pheochromocytoma;

Tracheal Collapse at level of mainstem bronchus and intrathoracic;
Sponaylosis Deformans Multilevel — cervical — sever, LS — mild;
Hydrocephalus — congenital COMS;

Patella luxation bilateral;

Previous right front leg trauma with resultant valgus deformity;
History of seizures with recent onset of grand mal and focal seizures;
Intermittent hyoonatremia/hypochloremia/hyperkalemia;
Hypothyroid;

Proteinuria;

Cortical blindness OD;

. History of hypertension — now borderline hypotensive;

Recent onset of lethargy, intermittent collapse and vomiting;
Elevated Spec cPI consistent with pancreatitis;

New onset of severe non-regenerative anemia;

Leukocytosis with a mild left shift;

Concern for pulmonary hypertension; and

Generalized poor lung inflation.

24. Dr. Schnier reviewed the dog's recent history of collapse and apnea. He was treated at
151 Pet Veterinary Centers and severe non-regenerative anemia was identified. The dog had
been hospitalized for diagnostics and treatment. No blood transfusion was performed at that
time. After discharge, the dog had another episode of collapse with a period of apnea. Dr.
Schnier mentioned that the dog may have experienced a mild seizure following one of his
episodes — Complainants reported that the dog had been experiencing seizures every 5 - 6
weeks. Previous seizure was in May and the last cluster seizure occurred in March. The dog
was on the following medications:

Imepitoin;
Levetiracetam;
Zonisamide;
Prednisone;
Omeprazole;
Levothyroxine;
Telmisartan;
Amlodipine;
FloVent;
Denamarin;

. Clavacillin;

Hydrocodone;

. Entyce; and

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21-45, Courtney Deer, DVM

n. Diazepam rectal gel.

25. Dr. Schnier examined the dog (W-3.5kg, T-103.2, P-120, R-90); he noted that the dog was
subdued but responsive. He was unable to walk in the hospital and demonstrated difficulty
standing — carpal valgus was noted, mostly in the right forelimb. The hind limbs contracted
forward. Mucous membranes were pink and a soft grade II/VI left systolic murmur was
suspected on auscultation with a sinus arrhythmia. Lungs ausculted clear in all fields although
intermittent episodes of panting and tachypnea were noted with increased respiratory effort
at times.

26. Dr. Schnier performed radiographs and an ultrasound on the dog. Radiographs revealed
generalized poor lung inflation consistent with recumbency and possibly exacerbated by
concurrent tracheal collapse. Associated right cranial atelectasis. Concurrent mild diffuse
tracheobronchitis and mild right cranial pneumonia were possible. There was a nonspecific
hepatopathy which could be associated with any infiltrative process. Elbow arthritis, Patella
luxation, and multifocal cervical and thoracolumbar IVDD.

27. Aodominal ultrasound revealed:

Mild to moderate hepatomegaly was noted with hyperechoic parenchyma. The hepatic
changes were suspected to represent a vacuolar hepatopathy. This could have been
associated with chronic prednisone administration or possibly, underlying
endocrine/metabolic disease. Bilateral renal changes were noted, consistent with chronic
kidney disease. Renal size appeared to be stable. Two small non-deforming hypoechoic
nodules were noted. The splenic nodules appeared to be consistent with a benign process.
No abnormalities were noted to account for the dog's signs of anemia. Primary differentials
include gastrointestinal blood loss vs hemolytic anemia.

28. Blood work and a urinalysis were performed. PCV = 23%; HCT = 17.8%; Cardiopet NT -
proBNP -2407; fecal occult blood test - positive.

29. The dog was administered the following:
Oxygen therapy;

lron dextran;

Cobalamin; and

LRS SQ;

29070

30. Dr. Schnier discussed hospitalization and packed red blood cell transfusion with
Complainants. Complainants wanted to avoid a transfusion at that time, however, a follow
Up appointment to have the dog's PCV rechecked on June 24! was scheduled. The dog
was discharged with instructions for Complainants to monitor the dog and continue current
medications but discontinue telmisartan and amolodipine. Complainants were to feed the
dog a low-fat diet. Detailed discharge instructions were provided to Complainants with the
dog's diagnostic results. An echocardiogram with a cardiologist was recommended and if

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the follow up blocd work revealed progressive anemia, a blood transfusion could be
warranted.

31. On June 23, 2020, the dog was presented to Dr. Matthews at VETMED for an
echocardiogram. The echo revealed left ventricular hypertrophy, mild valve insufficiency
and moderate pulmonary hypertension.

32. On June 24, 2020, the dog was presented to Dr. Schnier for a recheck. Upon exam, the
dog had a weight = 3.4kg, a temperature = 101 degrees, a pulse rate = 132b0m and a
respiration rate = 90bpm. The rest of the exam was noted to be the same as the June 224
exam. PCV = 17%; TS - 6.2. Dr. Schnier discussed the blood results with Complainants and
recommended a blood transfusion as the dog's anemia had progressed since 6/22. The
dog would be hospitalized for the transfusion and if no complications occurred the dog
would be discharged later that day.

33. The dog was hospitalized for the blood transfusion. No complications had occurred and
the dog was discharged later that evening. During the hospitalization, the dog was also
administered:

Sucralfate;

Levetiracetam;

Denamarin;

. Orbax;

Dex SP;

Cyclosporine; and

g. Clopidogrel.

™oa9T9

34, Discharge instructions were provided which were also discussed with Complainants. They
stated that Dr. Yeamans was contacted regarding the dog's condition - she indicated that
the zonisamide could have possibly triggered the dog's anemia and that it would be
reasonably safe to discontinue zonisamide at this time. However, phenobarbital may need
to be restarted if recurrent seizure activity was noted. The dog's fecal occult test was positive
indicating a possibility of gastrointestinal bleeding; however, melena and GI signs would be
expected with the dog's current level of anemia if GI bleeding was responsible for the dog's
signs. A recheck PCV and blood pressure was recommended on June 26! or sooner if the
dog was not doing well. Discharge instructions included a medication table that noted the
recent changes to the dog's medications.

35. Dr. Schnier stated in his narrative that prior to discharge of the animal, he advised
Complainants that BluePearl was staffed 24 hours a day with veterinarians and staff and they
could call anytime with questions or concerns. If the call was outside normal business hours,
they would speak with ER department staff. Dr. Schnier stated that he did not indicate that
he would personally be in the hospital or available 24 hours to speak with Complainants
directly. However, Dr. Schnier stated that he typically can be contacted by BluePearl staff by

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21-45, Courtney Deer, DVM

phone outside of his normal hours.

36. Later that evening, at 9:40om, the dog was presented to Dr. Deer due to a suspected
seizure. The dog presented obtunded and minimally responsive. Complainants reported that
the dog had a seizure at home and therefore rectal diazepam was administered. Upon
exam, the dog had a weight = 3.3kg, a temperature = 104.2 degrees, a heart rate = 150bom
and a respiration rate = > 60rom. Dr. Deer noted the dog appeared dehydrated based on
tacky mucous membranes and prolonged skin tenting. The gums were pale and scant
hematochezia was noted on the thermometer. An IV catheter was placed: the dog was
started on Normosol - R fluids and placed on oxygen while Dr. Deer spoke with
Complainants.

37. Dr. Deer stated in her narrative that she was frank with Complainants and expressed
concerns about the chances of the dog surviving the night. Complainants felt the dog sfill
had some fight left in him and approved overnight care. The dog was started on injectable
levetiracetam since the dog was too obtunded to eat/swallow — oral medications were
placed on the dog's treatment sheet with strict instructions to consult with the attending
veterinarians prior to administration due to his obtunded status and high risk of choking. The
dog's oral medications were not administered during her shift due to the dog being too
obtunded to eat. Keppra and pantoprazole were given to the dog IV.

38. The dog remained obtunded throughout the night but the elevated temperature
resolved with IV fluids and supportive care. Food was not offered as the dog was too
obtunded to swallow.

39. At 12:44am (6/25), Complainants were updated and advised that there were no further
seizures, the dog was in still in oxygen and critical. They asked about the dog's current PCV -
Dr. Deer explained that the dog was not stable enough to remove from oxygen and collect
a blood sample, which could put the dog at risk for another respiratory episode. While
monitoring the PCV was important, Dr. Deer did not want to worsen the dog's condition.

40. At 5:00am, the dog appeared more sedate that previously — blood pressure was too low
to read on the Doppler and his heart rate dropped to 70. Three doses of bolus fluids were
administered which brought the dog's blood pressure up — the dog's PCV = 49%; TP = 5.

4]. At 6:24am, Dr. Deer called Complainants when she felt the dog was stable enough to
step away. She discussed the dog’s episode of hypotension, bradycardia and the use of IV
fluids. Dr. Deer relayed that there was a delicate balance of fluid overload due to the dog
being diagnosed with pulmonary hypertension and mitral valve regurgitation recently.
Additionally, the dog's PCV = 49% was indication that the dog's current symptoms were likely
not related to anemia — pulmonary thromboembolism could be a possible cause of the
dog's decline. Complainants commented that they wanted to see what the internal
medicine doctor suggested as a next step. Dr. Deer explained that her associate, Dr.

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21-45, Courtney Deer, DVM

Meredith, would reach out to them once they open. The case was transferred to Dr.
Meredith at 7:00am.

42. Dr. Meredith reviewed the case with Dr. Deer — since his last visit, the dog had been
started on sildenafil by a cardiologist due to a diagnosis of pulmonary hypertension and due
to the concern of IMHA the dog was taken off zonisamide. Dr. Meredith evaluated the dog
and noted the dog was obtunded and laterally recumbent.

43. When Dr. Schnier arrived at work at BluePearl he had a message from Complainants — he
called Complainants and was advised the dog was being hospitalized at 15t Pet Veterinary
Centers. They discussed the dog’s condition and Complainants requested Dr. Schnier calll
the veterinarians at 1s Pet Veterinary Centers to get an update. Complainants then asked if
the dog should be transferred to BluePearl; Dr. Schnier responded that it may not be in the
dog's best interest if he was not stable — 15 Pet should be able to provide the same level of
care and treatment that BluePearl could provide. He stated that repeat advanced imaging
of the dog's head and thoracic cavity could potentially provide additional information
although advanced imaging was not available at BluePearl. Re-evaluation by the
neurologist could be helpful but the dog would need to be stabilized prior to considering an
MRI or CT.

44, Dr. Meredith spoke with Complainants that afternoon and expressed her concerns for the
dog. The dog's mentation was not appropriate and had declined significantly from when
she has seen him last. They discussed the ability of the dog to swallow at that time and
Complainants requested the dog remain on oral keppra instead of injectable. Dr. Meredith
was not convinced this would have any effect on the dog's mentation but they could try it.

45. Dr. Schnier then called Dr. Meredith to discuss the case — he suggested thoracic
radiographs and Dr. Meredith stated that she would consider that diagnostic. At that time,
she reported the dog remained obtunded although he was able to take oral medications.
Dr. Schnier thought the dog's current state could be related to post-ictal event associated
with seizures, and anticonvulsant treatment. He was also concerned about a stroke-like
event and discussed that a CT or MRI could be considered for further evaluation if possible.
Dr. Schnier and Dr. Meredith shared their concerns with the dog's quality of life. Dr. Schnier
noted if there was a concern for pulmonary thromboembolism or ischemic stroke, treatment
with enoxaparin could be added in addition to clopidogrel. Dr. Meredith stated she would
keep them updated and discuss the details of their conversation with Complainants.

4é. Dr. Meredith also spoke with Dr. Yeamans, the neurologist, regarding the case. Dr.
Meredith stated that Dr. Yeamans also had concerns with the dog's mentation and quality
of life. She felt the dog would either recover, or worsen. The dog may need a ventilator and
may not be able to ever come off the ventilator after being put on. If the dog's mentation
did not improve in 12 -24 hours, he would likely not recover.

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21-45, Courtney Deer, DVM

47. According to Dr. Yeamans, Dr. Meredith reached out to her to contact Complainants as
they did not seem to fully grasp the severity of the dog's clinical status and she had
discussed humane euthanasia with them. Dr. Yeamans reviewed the case and contacted
Complainants. She advised that she had been speaking with Dr. Meredith and they were
concerned with the dog's quality of life. Dr. Yeamans also advised that the dog would not
be stable to transfer, nor undergo anesthesia for further investigations into his mental state,
due to his respiratory compromise. She told Complainants that she was speaking with Dr.
Meredith to advise on further care for the dog and options for treatment to help the dog
return to a more normal mental status. However, all efforts had not shown significant
improvement in the dog's clinical status.

48. Dr. Meredith called Complainants to relay her conversations with Dr. Schnier and Dr.
Yeamans. She also advised that the dog had a seizure in the oxygen chamber, which meant
the dog had a grave prognosis and was less likely to recover. Dr. Meredith attempted to
contact a traveling internal medicine specialist without success. She told Complainants that
she was worried the dog would not make the transport to another facility to be evaluated
by internal medicine specialist; the dog was oxygen dependent and had another seizure. Dr.
Meredith would reach out to their criticalist for a possible consult (she was unavailable until
the next day). Complainants were to consider humane euthanasia.

49. According to the medical records, it appeared the dog was getting oral medications.

50. Dr. Deer took over the dog's care. She evaluated the dog - he was obtunded and
minimally responsive, similar to when she observed him earlier that morning. Dr. Deer stated
that around 7pm, before her evaluation, the dog began to flail and develop nystagmus, lost
control of bowel movement and urine. There were concerns of seizure vs another vascular
event. At this time, the dog had mild bradycardia and increased respiratory rate and effort.

51. The dog remained obtunded through the night and only became alert for medications.
He was uninterested in food or water therefore his medications required to be force fed.

52. On 6/26/20, around 7am, Dr. Deer contacted Complainants with an update. She
explained there was no change - the dog was still tachypneic, oxygen dependent, and
minimally responsive. There was no interest in food and had to be forcefully medicated
orally. Dr. Deer had another discussion with respect to the dog's quality of life, and humane
euthanasia. Complainants wanted to have the dog euthanized at home therefore Dr. Deer
stated they would continue to treat the dog until they could find an in-home euthanasia
service.

93. The dog's care was transferred to Dr. Meredith. Dr. Meredith stated that Complainants
called to advise the euthanasia appointment had been scheduled between 1 - 2pm that
day therefore she did not follow up with the criticalist. Due to the dog's status, he was
unable to take his oral medications therefore none was given and the dog was discharged

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later that day.
COMMITTEE DISCUSSION:
The Committee discussed comments that Dr. Deer made that Complainants were
concerned about were not unprofessional. It was the professional's judgment on a case that
was being relayed to another professional that was also treating the pet. Euthanasia is a
difficult topic. Veterinarians are there to try to diagnose a pet and provide the pet owners
with treatment options. People communicate and receive communications differently.
Dr. Deer and her staff closely monitored the dog and there was no need for a jingle collar or
other device to alert them if the dog would seizure. Someone had eyes on the dog the
entire hospitalization.
The Committee felt Complainants had unrealistic expectations.
COMMIITTEE’S PROPOSED CONCLUSIONS of LAW:
The Committee concluded that no violations of the Veterinary Practice Act occurred.
COMMITTEE’S RECOMMENDED DISPOSITION:

Motion: It was moved and seconded the Board:

Dismiss this issue with no violation.

Vote: The motion was approved with a vote of 4 to 0.

The information contained in this report was obtained from the case file, which includes the

complaint, the respondent’s response, any consulting veterinarian or witness input, and any
other sources used to gather information for the investigation.

fei

Tracy A. Riendeau, CVT
Investigative Division

Page i2

ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD
1740 W. ADAMS ST., SUITE 4600, PHOENIX, ARIZONA 85007
PHONE (602) 364-1PET (1738) FAX (602) 364-1039
VETBOARD.AZ.GOV

(Co nce oy oe
COMPLAINT INVESTIGATION FORM on

If there is an issue with more than one veterinarian please file a
separate Complaint Investigation Form for each veterinarian

PLEASE PRINT OR TYPE

FOR OFFICE USE ONLY

Date Received: New Ib, Abo Case Number: LI -45

A. THIS COMPLAINT IS FILED AGAINST THE FOLLOWING:

Name of Veterinarian/CVT; Dt. Courtney Deer _
Premise Name: 18t Pet Veterinary Centers

Premise Address: 0404 E Southern Avenue

City; Mesa State: AZ Zip Code; 85206
Telephone: (480) 924-1123

B. INFORMATION REGARDING THE INDIVIDUAL FILING COMPLAINT?:
Name: Frederick Milens and Ashanna Biliter

Address: sie acacia
city: = soni State == Zip Code:
Home Telephone: aaa? Cell Telephone:

*STATE LAW REQUIRES WE HAVE TO DISCLOSE YOUR NAME UNLESS WE CAN SHOW THAT DISCLOSURE WILL
RESULT IN SUBSTANTIAL HARM TO YOU, SOMEONE ELSE OR THE PUBLIC PER A.R.S. § 41-1010. IF YOU HAVE
REASON TO BELIEVE THAT SUBSTANTIAL HARM WILL RESULT IN DISCLOSURE OF YOUR NAME PLEASE PROVIDE
COPIES OF RESTRAINING ORDERS OR OTHER DOCUMENTATION,

C. PATIENT INFORMATION (1):

Name: (=a
Breed/Species; Pomeranian
Age: 14 Sex: M Color; Blonde
PATIENT INFORMATION (2):
Name:
Breed/Species:
2 ot MOON:

Age: _. Sex:

D. VETERINARIANS WHO HAVE PROVIDED CARE TO THIS PET FOR THIS ISSUE:
Please provide the name, address and phone number for each veterinarian.

See attached list of veterinarians.

E. WITNESS INFORMATION:
Please provide the name, address and phone number of each witness that has

direct knowledge regarding this case.
See list of veterinarians.

Attestation of Person Requesting Investigation

By signing this form, | declare that the information contained herein is true
and accurate to the best of my knowledge. Further, | authorize the release of
any and all medical records or information necessary to compleie the

investigation of this case.

Signature: LL fn ii |S

Oakes || 2080

Date:

v

Witnesses/Doctors

Dr. Jonathan Schnier

BluePearl Veterinarian Partners — Avondale
13034 W Rancho Santa Fe Blvd

Avondale, AZ 85392

(623) 385-4555

Dr. Courtney Deer

Dr. Nicolette Meredith
Trinity Taylor, Rehabilitation
1S Pet Veterinary Centers
5404 E. Southern Avenue
Mesa, AZ 85206

(480) 924-1123

Dr. Carmen Yeamans

Dr. Sarah Sterling

Dr. Paul Cuddon

Animal Medical & Surgical Center
17477 North 824 Street
Scottsdale, AZ 85255

(480) 502-4400

Dr. Jill Patt

Little Critters Veterinary Hospital
1525 N, Gilbert Road, #C-101
Gilbert, AZ 85234

(480) 696-7744 .

COMPLAINT SUMMARY

The Board should find that Dr. Deer violated A.R.S. § 32-2232 23 as well as violated R3-
11-501(1). Dr. Deer violated 32-2232(23) when she neglected C-=gaeiefcare when she failed to
administer any medicine to him for almost half a day. This conduct was not only detrimental to
Gear health but also made it difficult to tell what exactly was causing his issues. 1% Pet also
did not appear to be monitoring C gclosely with a jingle collar or other device to inform them
that he was having seizures when they were not watching him.

Dr. Deer also violated R3-11-501(1) when she failed to show respect for C jsid@tus as
Commit owners, or use professionally acceptable procedures. Significantly, the medical records
indicate that Dr. Deer told BluePearl on June 21 that we were having difficulty understanding
that “it might be time” while she did not inform us of that opinion at that time. We would have
gone to a different provider had we known that this was Dr. Deer’s opinion. Further, on the
night of June 24", Dr. Deer and 1 Pet failed to notify us of a severe decline in Camssiiagestatus
even though we requested them to contact us at any time if there were changes in his current
health.

Asa preliminary note, Casqumi1as long-suffered from seizures and we have been very
involved in his care and the different procedures used for his care so that we could give him the
best quality of life and best chance of managing his seizures. The following is a summary of the
concerns that we have and the history of Dr. Deer’s involvement in Coggummme care around the time
of Ceaeldis passing.

FACTUAL NARRATIVE UNDERLYING THE COMPLAINT

Dr. Deer (along with Dr. Meredith, mentioned in a separate complaint) first treated Gqasali
at Ist Pet Mesa’s emergency department on June 19, 2020 and June 20, 2020 following an
episode of collapse. Tests were performed at that time and initial supportive treatment provided
including placing Caggg@in oxygen. Further conversation with Dr. Deer very early on June 20
indicated that Cammi#thad very low PCV and/or hematocrit values and that the most likely
explanation of his symptoms was immune-mediated hemolytic anemia (as opposed to
undiagnosed internal bleeding), and she expressed her concern that if his values dropped any
lower that he would require a transfusion.

Cg was subsequently discharged by Dr. Meredith late in the day on June 20, 2020 and
suffered another episode of collapse after going outside to urinate early on the morning of June
21, 2020. We immediately took Caimi back to Ist Pet for further investigation. Dr. Deer
examined Caail® and indicated that he seemed stable but should be seen by internal medicine,
something that Dr. Meredith had previously said they would do 1f necessary when he was first
admitted on June 19th. Dr. Deer indicated that neither of the internal medicine specialists that Ist
Pet works with would likely be available to assist as it was now Father’s Day, and she also
contacted VetMed to learn that there would be a wait of several hours (in our car with Cyggea@ in
the heat, with his newly-occurring breathing difficulties) with no guarantee of being seen there.
We also asked Dr. Deer contact BluePear! directly to see if they could bring him in given his
condition but Dr. Schnier was not available to be on call; we had already made an appointment

with Dr. Schnier (Cgggmiginternal medicine specialist) for the morning of June 22, 2020 upon his
admission to emergency but we were worried about any further decline in his condition.

Having no other options available we brought Cag back home and waited for the next
day’s internal medicine appointment at BluePearl, with Dr. Deer stating that she would call the
Ist Pet specialists to see if they could have any availability under the circumstances. We heard
nothing back so I called later in the day for an update, and she returned our call indicating that
nobody was available at Ist Pet to see him. Cq™& was then seen by Dr. Schnier at BluePearl and
Dr, Matthews at VetMed as detailed elsewhere in our documents.

Gates, subsequently had what appeared to be a major seizure episode at home shortly after
discharge from BluePearl on June 24th. We took Cmmto Ist Pet as it was the closest emergency
facility and I was-concerned that the abrupt discontinuation of zonisamide may have triggered
rebound seizures and the potential for status epilepticus (such warnings for zonisamide are
standard in human use).

Upon arriving, Dr. Deer said that he was in far worse condition than her last examination
of him on June 21st and that she was very concerned for his continued quality of life. I
mentioned that the seizure episode (if that’s what it was) had just happened and that Cammphad
been dosed with rectal diazepam which usually leads to a very sedate or obtunded state for quite
some time and that his current state was not representative of a continued decline since the last
examination. I also mentioned that he had been examined by both internal medicine and
cardiology, both of whom seemed to indicate that his prognosis was reasonable, and that he had
actually been doing slightly better since the blood transfusion earlier in the day.

She asked what we wanted her to do and I relayed Dr. Schnier’s instructions that in the
event of an emergency we were to take him to emergency and then have them get in touch with
BluePearl. I also stated that I wanted them to continue to monitor his condition and intervene as
necessary until next steps could be coordinated with internal medicine and/or neurology. J also
mentioned that I had already contacted both BluePearl and AMSC regarding the change in
C gm condition and that Dr. Yeamans would not be available until the following morning but
we were hoping Dr. Schnier would be available based on our conversation at discharge, but that I
expected further instructions from him no later than the following morning. Dr. Deer also stated
that she might be unable to give C @Rsome of his medications given his current mental state as
they were in pill form or not widely available in the United States; I told her that I understood
that as he was often drugged after a seizure and that sometimes we had to grind up his pills and
give them via oral syringe at home.

I have concerns regarding the marked deterioration in C ggiii@status and lack of
notification. When we visited C @ion the night of June 24th he appeared very drugged, panting
with his eyes open and staring off, but this was very common behavior for him after a large dose
of diazepam combined with the intravenous levetiracetam he had been given in hospital; we had
seen very similar behavior during other hospitalizations for seizures, and he was very sensitive
not only to the drugs but to the manner of administration (tablet levetiracetam affected him the
least, liquid levetiracetam more so, and intravenously the most). However, by the following

morning during our next visit, he seemed mostly unaware of his surroundings, though we were
told he was able to chew pills. We were not notified overnight of any change in status and
therefore had no opportunity to investigate options for transfer until his condition had already
declined severely. I would also note that while we had expectations that Dr. Schnier was going to
be available to coordinate based on our conversation with him at discharge, this did not occur,
and |st Pet once again was unable to bring any of their own internal medicine or critical care
specialists to bear on the problem as well despite the deterioration in Cqgmgms case.

I also discovered after reviewing Ist Pet’s records (at least based on my reading) that
Cmmmdid not receive his scheduled medications for almost half a day until he was able to chew
them in his mouth and swallow them earlier that morning (though I am curious how he could be
both nonresponsive and be able to at least recognize he had medication in his mouth to chew and
swallow). When I agreed that it was acceptable if he couldn’t receive his medications, I was
expecting a limited delay relating to post-ictal issues with the seizure or sedation from the
diazepam; I did not realize they would be discontinued for such a length of time. Also, the
omeprazole that C @ijmwas on for neurological concerns related to intracranial pressure had been
completely replaced with another proton pump inhibitor that to my knowledge is not known to
have the same effect, which may or may not have contributed to his greater obtundedness and
appearance of seizure activity. For reference, an earlier attempt by Dr. Knowles (Cqgggiieidiormer
neurologist at VetNeuro) to discontinue his omeprazole was followed by a severe episode of
cluster seizures leading to hospitalization and difficulty regaining any seizure control.

In addition, I am unsure to what extent Ist Pet Mesa followed Cgjigumgp antiseizure
protocols when seizures were reported, as Cag@has a history of cluster seizures, particularly as
his zonisamide had been discontinued abruptly based on medical advice from Ist Pet Mesa and
Dr. Yeamans. Nearly a// of Cegjggmp medications, including his primary antiseizure medication,
were discontinued for almost half a day under Dr. Deer’s care; this would make it challenging
for us to determine in the context of euthanasia whether some of the obtundedness would have
been the result of seizure activity or the result of stroke or other damage to the brain. Dr. Deer
noted a major seizure-like event the night of June 25th that appears to have been treated with
intravenous levetiracetam, but historically this was often insufficient to break a cluster seizure in
CMs case, C @MBdid have what appeared to be small seizures at home while waiting for
euthanasia, so | do wonder if he was having other small seizures that went unnoticed. There did
not appear to be a “jingle collar” or any other means of alerting staff to a seizure during our
visits.

Lastly, after reviewing BluePearl’s records, I have additional concerns regarding Dr.
Deer’s overall conduct. During Dr. Deer’s initial call to BluePearl on our behalf on June 21st, it
appears that she told them that 1st Pet had discharged C@jiilome days ago with a
recommendation to see internal medicine, but that we had not followed up and taken him to
internal medicine, In reality, Cegaimmhad been discharged by Dr. Meredith at Ist Pet only late the
previous day, and neither Dr. Meredith nor Dr. Deer had been able to arrange any on-call
specialist care by any of the specialists affiliated with their hospital or at VetMed (we had

independently scheduled an appointment with Dr. Schnier ourselves at the earliest available
opportunity) during his hospitalization or thereafter.

More disturbingly, Dr. Deer told the receptionist at that time that my wife and I were
“having difficulty understanding that it might be time.” Dr. Deer had not suggested to us that she
felt Cqgs should be euthanized at this point, and neither Dr. Schnier nor Dr. Matthews made
such dire assessments of his prognosis after having the chance to evaluate C ggg! find it
particularly disturbing in that Cagmmhad been going to Ist Pet up to twice a week for rehab for
months and made great progress, and yet Dr. Deer (unbeknownst to us) seemingly believed it
would be time to euthanize him on the basis of a yet-undiagnosed acute medical issue and
attempted to covertly advocate for euthanasia with another veterinarian. Had I been aware of
these facts I would not have entrusted Ist Pet with C@limduring his subsequent emergency
hospitalization.

Also, there are no further notes in the BluePearl records that Dr. Deer attempted to
contact BluePearl during Ceggggy following June 24th hospitalization despite our direction to
coordinate with BluePearl based on Dr. Schnier’s discharge instructions. The records only note
that Dr. Meredith. attempted to contact Dr. Schnier the following day, and this matches the Ist
Pet records indicating that Dr. Meredith, not Dr. Deer, tried to call.

—November __, 2020 7;

ae
ourtney Deer, DVM) eo -
Of

To Whom It May Concern:

Cali Milens initially presented to 1°* Pet Mesa on June 19"", 2020 to Dr. Nicolette Meredith at
Spm. My shift started at 7pm and Dr. Meredith rounded me the following information about

C a

C gm was a 14-year-old Pomeranian that presented for concerns related to a collapse after
going for a walk. He had an extensive history of hydrocephalus, seizures, Chiarai malformation,
syringomyelia, medially luxating patella’s, hypertension, hypothyroidism, collapsing trachea,
intervertebral disk disease, a surgically removed pheochromocytoma some years prior,
suspected fractured right thoracic limb (occurred before owners adopted him). He was also
evaluated by his rDVM on 5/20/2020 for recheck liver values (ALT 290, ALP >993, GGT 211,
resting bile acids of 54.6, positive spec cPL). Also, the night prior to presentation and the
morning of presentation the owners observed 30 second seizures with collapse and white to
pale mucus membranes. On presentation to the clinic he was unable to stand (per owners this
was normal for him, he hadn’t been ambulatory for some time) with muddy mucus membranes
and overall weakness. His lung sounds were harsh in all 4 quadrants and his Spo2 was 77% on
room air. Bloodwork performed in hospital revealed a macrocytic, normochromic anemia (22%
PCV), neutrophilia (13,190), leukocytosis (18,420), monocytosis (2,070), an elevated bun (42),
elevated ALT (187), elevated alkphos (1758), elevated GGT (51), and an elevated lipase (5085).
He also had a Primary metabolic acidosis, with normal anion gap, with superimposed
respiratory acidosis. Radiographs revealed hepatomegaly, abnormal gastric contents
(radiologist was unsure if food or foreign material), degenerative changes of the cervical and
thoracolumbar spine, suspected collapse of the bronchus to the right cranial lung lobe (unsure
if due to poor inflation of the lung vs. edema).

An ECG was performed and a normal rhythm was noted. Slide agglutination revealed mild
clumping. Owners approved 12-24 hours of oxygen and supportive care, with plans to start
treatment for suspect IMHA +/- a blood transfusion. The goal was to get Cemmusaut of oxygen
support overnight, start treatment for IMHA and possible pneumonia (official radiology report
was still pending at that time), as well as monitor PCV to see if patient would need a blood
transfusion.

On June 19", 2020 at 7pm | did my physical exam on C caer. Cceagaanvvas QAR — initially he was
sleeping in oxygen (respiratory rate around 40 bpm, moderate to mild effort). During my exam
he became brighter and more alert while | was examining him. He became tachypneic during
my exam but did not return to respiratory distress. His mucus membranes were pale and he
was nonambulatory. A full neurologic exam was not performed due to patients need to be in an
oxygen kennel.

During my shift, we were able to medicate him with the following medications, as he was eating
and alert enough to consume food and medications —
8pm - Prednisone 1mg tablet po .
8pm — Zonisamide 25 mg po

8pm — levothyroxine 50 mcg po

8pm — Imepitoin 100 mg capsule po

8pm — FlowVent ~ 1-2 puffs inhalant

8pm — Telmisartan 0.2 ml PO

9:50pm — Levetiracetam 312.5 mg po

11:20pm — Unasyn (30mg/ml) 102 mg/ 3.4 ml iV slow
7:20am — Omeprazole 20mg po

A comprehensive CBC was submitted to IDEXX at 3am. A manual smear was evaluated at that
time and spherocytes were noted on the slide. A PCV/TP at 3am was 20%/7.2 g/dl lipemic, with
a mild hyperchloremia and hyperkalemia.

During the night he remained in oxygen support with weaning oxygen percentage in the
Snyder. His SpO2 at 3am was 87%, but due to his persistent stress when moved out of the
oxygen kennel he was continued on O2 support in the Snyder.

At 1:30am owners called for an update. Discussed worsening anemia (20% from 22%), also the
spherocytes and changes noted on the manual assessment of his blood smear. | also discussed
differential diagnosis for IMHA and causes — sulfa drugs, etc. Owners asked if Zonisamide could
be at fault? We discussed this seemed unlikely, as he’d been on the Zonisamide for quite some
time. Owner asked if discontinuing the Phenobarbitol could have been at fault, due to
cytochrome P450? We discussed this being a stretch but still possible, we can taper and
discontinue zonisamide if recommended by neurologist but at risk for increased to continued
seizures at that point. Also, stopping the zonisamide at this point won’t “slow” IMHA if it’s the
cause. Also discussed if anemia is worsening then a blood transfusion may be indicated,
because the collapse owner noted may have been related to hypoxia from anemia. Also
discussed quality of life with owners and humane euthanasia — owners reported they were not
interested in discussing euthanasia at this time.

Owners wanted us to reach out to Dr. Schnier (Internal Medicine at Blue Pearl Avondale) and
Dr. Yeamans (neurologist at ANIC) to discuss the next steps. | advised owners at 1am | wouldn’t
be able to get ahold of either of them, but | could at least call Blue Pearl and update them.
Owner approved this.

At 1:39am | called Blue Pearl Avondale. Discussed C gamis currently hospitalized with us, would
like them to let Dr. Schnier know that the owner is interested in consulting with him.
Receptionist mentioned this is unlikely, as it was Saturday and specialty is not in on the
weekend. She said she would put a call to him in the morning to discuss the case. | passed this
information along to Dr. Meredith in the morning during rounds.

At 6:37am | updated owners — advised that Ci @™was still in O2 support, when we tried to wean
him too much through the night be became uncomfortable. | let him know | reached out to Blue
Pearl Avondale to let them know he was here. Discussed it was unlikely to get a consult on the
weekend, but they would let him know. Also discussed plan going forward — potentially
lowering zonisamide, also that the bloodwork changes are partially consistent with IMHA, but
other rule outs exist and so it was not a definitive diagnosis. At 7am | rounded Cito Dr.
Meredith for continued care and when | returned that night, June 20, 2020, Caguehad been
discharged to the owners.

On June 21* 2020 at 4am Cag again presented to 1° Pet Mesa for another episode of collapse.
Owners reported that they took him outside to urinate and he collapsed. He was pale and
nonresponsive after they took him for a walk early this morning.

On physical exam: he was quiet, alert and responsive. He was tachypneic with mild to moderate
increased abdominal effort with an increase in bronchovesicular sounds in all lungs, but less
than on previous examination when hospitalized. He remained unable to ambulate as
previously described. SpO2 was difficult to obtain on presentation. A PCV was 22%, consistent
with last PCV reading yesterday.

| phone owners (via COVID protocol) to discuss that patient appears back to “normal”, as in he’s
consistent with how he looked the day before when hospitalized. We discussed causes of his
collapse, such as syncope, pulmonary hypertension, anemia, arrhythmia, etc. We discussed
hospitalization and acute care until his follow up Blue Pearl Avondale on Monday. We also
discussed a cardiology consult to evaluate pulmonary hypertension and if there’s cardiac causes
for his issues. Owners expressed interest in a cardiology consult. Discussed that because it was
4am on a Sunday, getting a cardiology consult right away was highly unlikely, but | could reach
out to VetMed (they’ve gone there in the past). We also discussed Dr. Church, but given that it
was Fathers’ Day I was unsure if we could get ahold of him. Owners elected to have me reach
out to see about consult. Owners asked if Cajamp could wait in the car with them while | reached
out to specialists, as we were in COVID protocol and no owners were permitted inside the
facility at that time. We allowed Cag to remain in the car with owners while | called specialty
clinics,

4:40am — Called AVECC to discuss transfer/consult with Dr. Church and was informed that he
was out of town. :

4:44am — Called VetMed, transferred to ER doctor. Went over presentation with clinician,
including history and concerns. Asked if ER echocardiogram was possible? Clinician stated no —
patient has no cardiomegaly on x-rays, has no heart murmur, they would not call cardiologist in
on Sunday to perform echocardiogram. ER clinician discussed Holter Monitor and other things
they may be able'to provide, but echocardiogram and cardiology consult was highly unlikely.

| placed a call to owner (Mr. Milens) after calling AVECC and VetMed and went over discussion
with both specialists. AVECC’s cardiologists not in town, VetMed didn’t guarantee cardiology
consult today (Sunday) or even Monday. Discussed transfer to VetMed now so owners could

continue follow up there. At that time owners elected to take patient home and monitor him,
but did remark they were concerned he wouldn’t survive until Monday. | advised owner | would
pass this conversation on to Dr. Meredith to see if Dr. Eberhart or Dr. Greene would be
available tomorrow for an AUS. Owners took Cody home that morning.

| returned to work at 7pm on June 21, 2020 and had a message to call Mr. Milens . | returned
the call at 7:43 pm after | came on duty for my night shift. Per owners Cumumseemed to be okay,
just sedate — but they were unsure if it was due to medications or his illness. They also
indicated that he was resting well, eating and drinking, taking medications.

On June 24" 2020 C Mi presented for a suspect seizure at 9:40pm.

Mr. Milens had taken him to a cardiologist on June 23", 2020. An echocardiogram revealed low
to moderate pulmonary hypertension, so sildenafil was added to his medication regiment. He
was also diagnosed with mitral valve regurgitation, most likely due to historic hypertension
from his previously resected pheochromocytoma.

Per owner they followed up with Blue Pearl Avondale on June 24" 2020. They sent out a
comprehensive CBC, which revealed moderate anisocytosis, moderate polychromasia, a
worsening neutrophilia, lymphopenia, monocytosis, and a neutrophilia. His anemia appeared
regenerative. His PCV was 17% at that time, so they performed a blood transfusion that
brought his PCV to 40%. Dr. Schnier had consulted with Dr. Yeamans at that visit and she
recommended discontinuing Zonisamide due to it possibly triggering his anemia. She did
remark that phenobarbital may need to be restarted if the seizures return. At that time, they
also tested him for occult fecal blood, considering this as a cause for his progressive anemia,
but questioned itias a singular cause due to his lack of melena or hematochezia. Sucralfate was
added for concerns for GI bleeding.

When he returned home from that visit C egriad a seizure, So owners administered rectal
diazepam at 8pm:

On presentation at 9:40pm C «mwas obtunded and minimally responsive. He appeared avisual,
with an absent menace and inability to track. He appeared clinically dehydrated due to tacky
mucus membranes and prolonged skin tent. His gums were pale and scant hematochezia was
noted on the rectal thermometer. He also had a temperature of 104.2 Fahrenheit rectally.

His SpO2 was 98% on room air. A peripheral IV catheter was placed and he was put into the
Snyder while discussing with the owner due to possible traumatic brain injury from seizure.

At this time, | had a very frank discussion with owners— patient is obtunded, transfusion did not
help patient improve, he also had an elevated temperature. We discussed his suffering and
unnecessarily prolonging his life. Owners felt he was more alert after his transfusion and felt he
had “some fight still left in him.” | was honest with the owners about his chances of surviving
the night. Owners approved overnight care, with plans to discuss with internal medicine in the
morning to determine if any other changes were needed.

Cgprvas started on Norm-R at 11 ml/hr, Levetiracetam 312mg injectable since patient was too
obtunded to eat/swallow, oral medications were put on his treatment sheets with strict
instructions to consult with attending DVM prior to administering due to his obtunded status
and high risk of choking. His oral medications (Denamarin, Sildenafil, Orbax, Levothyroxine,
atopica, Omeprazole, Imepitoin, Clavacillin, Clopidogrel and Sucralfate) were not administered
during my shift as he was too obtunded to eat. Medications with injectable options (Keppra,
pantoprazole) were given IV.

Through the night and into the morning he remained obtunded, but his elevated temperature
resolved with IV fluids and supportive care. His SpO2 dropped to 90% at 1am, and again to 30%
at 5am but his respiratory rate remained consistent. Food was not offered, as patient was too
obtunded to swallow.

At 12:44am owner called for an update. Advised patient was unchanged, still in O2 support with
no further seizures but remained critical. Owner remarked he was glad for the improvement
despite no improvement being mentioned in this conversation. Owner asked about the current
PCV? Discussed patient was not stable enough to remove from O2 support and risk putting him
into another respiratory fit/episode attempting to draw blood. Historically he was difficult to
draw blood from due to recent hospitalization, multiple historic blood draws, etc. While | felt
monitoring the PCV was important, | did not suspect a drop that drastically over the short time
and was more concerned about not worsening his condition. | reiterated my concerns with
surviving the night. Owners understand, remarked they will call later for an update.

At around 5am patient appeared more sedate than previous examination. A blood pressure
could not be obtained because it was too low to obtain on the doppler, his heart rate had
dropped to 70bpm (previously it had been 130-150 bpm). A 30 mL Norm-R bolus was given. A
repeat blood pressure was too low to read as well. He was given another 30 mL IV bolus,
bringing his blood pressure to 74/49 with a MAP of 57, He was given another bolus, and his
blood pressure improved to 138/79. His PCV was 49% with a TP of 5 g/dl clear at that time.

| placed a call to owners at this time after | felt Caggmwas stable enough to walk away from at
6:24am. | remarked on his episode of hypotension, bradycardia. Discussed using IV fluid boluses
to remedy but worried he’ll need hetastarch if the hypotension returns. We’d be walking a
delicate balance of fluid overload, mostly due to the fact that patient was diagnosed with
pulmonary hypertension and mitral valve regurgitation recently. Also discussed current PCV at
49%, meaning his current symptoms are likely not related to anemia. We also discussed
pulmonary thromboembolism as a possible cause of his sudden decline. Owner stated at that
time he wanted to see what Blue Pearl internal medicine suggested as the next steps. | advised
that the day doctor, Dr. Meredith, would reach out to them, as they open after my shift had
concluded.

| transferred his case to Dr. Meredith at that time.

On the evening of June 25", 2020, | returned to my shift and was rounded Cee case by Dr,
Meredith. Per her rounds, Cvatttime mained oxygen dependent through the day, minimally
responsive to quiet. They were able to medicate him orally through the day via pilling him, as
he went from comatose/obtunded to quiet, alert and responsive in the early afternoon. Owners
felt that switching from injectable Keppra to oral Keppra would greatly improve his mentation.
Repeat radiographs of his thorax were also performed due to his worsening respiratory distress
and SpO2. Radiographs revealed increased pleural fluid and pulmonary opacities most
consistent with edema or inflammatory disease.

Per Dr. Meredith she’d discussed C. gum case with both Dr. Yeamens and an internal medicine
specialist. Dr. Yeamens had remarked that she’d had a quality of life discussion with ( sumjgijggs
owners. Internal medicine specialist was concerned about a PTE vs. stroke vs. seizures given his
sudden deterioration. He suggested adding clopidigrel, but was worried about quality of life
given his mentation and his rough recovery. Around 7pm he began to flail and developed
nystagmus. He also lost control of his bowel movements and urinated on himself. Concerns at
that time included seizure vs. another vascular event.

On my physical exam at 8:20pm Cemgpmewas obtunded and minimally responsive, much like he
was earlier that morning when | left. He had mild serous nasal discharge with no ocular
discharge and remained nonambualtory, as described through his entire hospitalization. He also
appeared to have mild bradycardia (his heart rate was 107, had been closer to 130-150
previously). His respiratory rate and effort were also increased from earlier morning exam. His
IV catheter was patent and flowing. He was on Norm-R at 11 mls/hr.

Through the night he was medicated as follows —

8pm — Clavamox 62.5 mg 1 tablet po, Flovent 1 puff intranasally, prednisolone 3mg/ml] 1.2
ml/3.6 mg po, imepitoin 1 tablet po, Sildenafil 3mg tablet % tab po, clopidagril 75mg tablet %
tab po

12am — Atopica 10mg capsule — 1 capsule po

2am — Sucralfate 100 mg/ml — 2 mL po slurry

3am — Levetiracetam 250mg tablet — 1.25 tablets po

Patient remained unchanged through the night, remaining depressed to obtunded and only
becoming alert for medications. He was uninterested in food or water, so we had to be force
fed his medications.

| placed a call to the owners at 6:48am for an update — advised patient was unchanged. He was
still tachypneic with poor oxygen saturation (remaining at 90-89% through the night on oxygen
support) and minimally responsive. He had no interest in food or water and had to be forcefully
medicated orally.‘Had another discussion with owners about quality of life, and humane
euthanasia. Owners wanted Ce to be euthanized at home. We discussed keeping Cogs in
hospital until they could find an in-home euthanasia service. His treatments would be
continued in the interim.

At 7am | rounded Dr. Meredith Ca@@liPcase for continued care until owners took him home for
humane euthanasia. This was the extent of my involvement in this case.

In closing, | want to state that | sympathize with the owners for their loss but honestly feel that
my colleagues and | did everything we could for Cigjgand were forthright and honest with his
owners about his medical condition during the time we cared for him. Thank you.